The social and health consequences of the war for Ukrainian children and adolescents: a rapid systematic review.

OBJECTIVES: Despite the growing interest on the Russian-Ukrainian war and its repercussion on the children's health, there is no previous systematic review compiling the current evidence on this topic. This study conducted a rapid systematic review to investigate the current findings concerning the impact of the Ukraine war on the social and health aspects of the Ukrainian pediatric population. METHODS: A rapid systematic review was conducted. PubMed, Scopus, CINAHL, PsycINFO, Web of Science, and Virtual Health Library (BVS Spain) were searched between February and April 2023. In addition, high-impact journals and institutions focused on pediatric health and human rights were also consulted. All relevant original articles, letters, editorials, and policy papers assessing the health and social repercussions of the war on Ukrainian children were included. RESULTS: From 134 publications matching the search criteria, 23 were included. These publications were categorized into three distinct domains: 'Public health challenges for the physical and mental health of children and adolescents', 'Lack of Healthcare resources and initiatives to mitigate suffering', and 'Policies, Government, and Children's rights'. Our findings revealed that the war is seriously impacting the life and the health of Ukrainian children, resulting in worse physical and mental health outcomes and perpetrating a deprived situation. To overcome such problems, several initiatives have been proposed by European and non-European countries, relying mostly on receiving refugees, providing mental health support, complementing lack of resources, and establishing policies to improve health care. CONCLUSION: It could help health professionals, policy makers, and governments to plan preventive, promotive, and therapeutic strategies for Ukrainian children.

Experiences of health and social professionals using care technologies with older adults during the COVID-19 pandemic: A qualitative study.

OBJECTIVE: To investigate the perceptions and experiences of health and social care professionals concerning the use of technology for the care of older adults during the COVID-19 pandemic. DESIGN AND MEASURES: A phenomenological qualitative, exploratory, and descriptive design using semi-structured interviews. SAMPLE: Twenty Spanish health and social care workers in six Spanish cities between February and July 2021, during the COVID-19 pandemic. RESULTS: During the COVID-19 pandemic care workers have become more familiar with technology devices, but they also recognize certain barriers for the implementation of technology, mainly in nursing homes and homecare, related to concerns of lack of humanization and difficulties in accessing and using these devices. CONCLUSION: Politicians and social and healthcare managers should be aware of the benefits of techno-care, reducing the difficulties in implementing it and making more funding and further training available to care providers.

How do cultural factors influence the provision of end-of-life care? A narrative review.

BACKGROUND: Culture influences the way in which patients, families and professionals provide care and undergo decision-making at the end of life. OBJECTIVE: Therefore, our research questions were: How do cultural aspects influence the needs, perceptions, and experiences of patients and their families in end-of-life care? What implications does cultural diversity have for professionals who care for individuals at the end of life? METHODS: A narrative review was conducted between June and July 2022. Articles published between 2017 and 2022 in peer-reviewed journals were included. RESULTS: A total of 43 studies were included. Our findings were grouped into four themes: 1) places to die and preferences about healthcare interventions (e.g. parts of the immigrant population tend to receive more aggressive and invasive interventions); 2) advance care planning and verbalization of death (e.g. less use of ACP in some minority groups); 3) rituals and family involvement during healthcare; 4) professionals addressing multiculturalism in care at the end of life (e.g. lack of training in addressing the context of multiculturalism). CONCLUSIONS: These findings could contribute to making professionals more aware of cultural aspects that influence the process of death and highlight the need for further training in the handling of such situations.

The efficacy of religious and spiritual interventions in nursing care to promote mental, physical and spiritual health: A systematic review and meta-analysis.

BACKGROUND: Spiritual interventions have proved to alleviate suffering, help the patient to prepare for end of life issues, improve quality of life, and well-being. OBJECTIVE: This study aims to investigate the efficacy of religious and spiritual interventions in nursing care to promote mental, physical and spiritual health as compared to control groups not receiving such care. METHODS: This is a systematic review and meta-analysis of clinical trials from SCOPUS, PUBMED, Web of Science and CINAHL databases. The searches were carried out between May and July 2020 without restrictions concerning the date of publication. Peer-reviewed articles published in English, Portuguese or Spanish, focusing on nurses were included. This study followed the PRISMA guidelines. In addition, the CONSORT and The Cochrane Collaborations tool for assessing risk of bias were followed. RESULTS: The search process identified 1308 publications, 18 randomized controlled trials were included for the systematic review and 9 for the meta-analysis. The meta-analyses revealed that spiritual interventions were associated with lower mental health symptoms (SMD = -6.91 [-9.83,-3.98], p < 0.001, I2 = 99 %), greater well-being (SMD = 1.26 [0.58, 1.93], p < 0.001, I2 = 94 %) and higher levels of spirituality (SMD = 0.48 [0.29, 0.67], p < 0.001, I2 = 31 %) as compared to individuals in the control group. CONCLUSIONS: Spiritual interventions seem to be effective to promote health, as seen for mental health, spirituality, well-being and physical outcomes. Nevertheless, more than half of the studies have a high risk of bias in any of the dimensions evaluated and there is an important heterogeneity among interventions and outcomes. This is particularly important to nurses and nurse managers who want to provide a holistic care to their patients.

Spiritual care in critically ill patients during COVID-19 pandemic.

INTRODUCTION: Spiritual care has a positive influence when patients are subjected to serious illnesses, and critically ill situations such as the case of the COVID-19 pandemic. PURPOSE: The purpose of this study was to investigate the perceptions and attitudes of nurses working at critical care units and emergency services in Spain concerning the spiritual care providing to patients and families during the COVID-19 pandemic. METHODS: A qualitative investigation was carried out using in-depth interviews with 19 ICU nursing professionals. FINDINGS: During the pandemic, nurses provided spiritual care for their patients. Although they believed that spirituality was important to help patients to cope with the disease, they do not had a consensual definition of spirituality. Work overload, insufficient time and lack of training were perceived as barriers for providing spiritual healthcare. DISCUSSION: These results support the role of spirituality in moments of crisis and should be considered by health professionals working in critical care settings.

The influence of spirituality and religion on critical care nursing: An integrative review.

BACKGROUND: Spiritual care could help family members and critically ill patients to cope with anxiety, stress and depression. However, health care professionals are poorly prepared and health managers are not allocating all the resources needed. AIMS AND OBJECTIVES: To critically review the empirical evidence concerning the influence of spirituality and religion (S-R) on critical care nursing. METHODS: An integrative review of the literature published in the last 10 years (2010-2019) was conducted in PubMed, Scopus, CINHAL, PsycINFO, Web of Science, Cochrane and LILACS. In addition, searches were performed in the System for Information on Grey Literature in Europe and the Grey Literature Report. Quantitative and/or qualitative studies, assessing S-R and including health care professionals caring for critically ill patients (i.e. adults or children), were included. RESULTS: Forty articles were included in the final analysis (20 qualitative, 19 quantitative and 1 with a mixed methodology). The studies embraced the following themes: S-R importance and the use of coping among critical care patients and families; spiritual needs of patients and families; health care professionals' awareness of spiritual needs; ways to address spiritual care in the intensive care unit (ICU); definition of S-R by health care professionals; perceptions and barriers of addressing spiritual needs; and influence of S-R on health care professionals' outcomes and decisions. Our results indicate that patients and their families use S-R coping strategies to alleviate stressful situations in the ICU and that respecting patients' spiritual beliefs is an essential component of critical care. Although nurses consider spiritual care to be very important, they do not feel prepared to address S-R and report lack of time as the main barrier. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Critical care professionals should be aware about the needs of their patients and should be trained to handle S-R in clinical practice. Nurses are encouraged to increase their knowledge and awareness towards spiritual issues.

The Role of Spirituality and Religiosity in Healthcare During the COVID-19 Pandemic: An Integrative Review of the Scientific Literature.

The pandemic caused by the new coronavirus SARS-CoV-2 has been affecting populations globally since the end of 2019. Previous studies have indicated that spirituality in these times of crisis serves as a source of hope and well-being that helps people get through the day. This study investigated the role of spirituality and religiosity in healthcare during the COVID-19 pandemic. An integrative review of the scientific literature available on PubMed, Scopus, and Web of Science databases and a review of the gray literature in the Information System on Gray Literature in Europe (OpenGrey) were carried out. From a total of 1,338 articles searched; 25 articles were included in this review (22 quantitative observational, 2 qualitative and one randomized controlled trial). Our findings revealed the importance of including spirituality in clinical practice for both health professionals and patients. On the one hand, spirituality can be considered a good coping strategy used by healthcare professionals to promote mental health and well-being during the COVID-19 pandemic and resulting in greater patient satisfaction with the care given. On the other hand, addressing spiritual needs of individuals leads to a reduction in stress, anxiety, depression, and an increase in resilience and hope among patients.

How Does Confucianism Influence Health Behaviors, Health Outcomes and Medical Decisions? A Scoping Review.

The aim of this study is to analyze the influence of Confucianism on health behaviors, health outcomes and medical decisions. The research was conducted using the following databases: PubMed, Scopus, CINHAL, PsycINFO and Web of Science, without restrictions of language and year of publication. The search process identified 833 publications matching the search criteria, and after the review process, 40 articles were included. Family is a central aspect of Confucianism, and it seems to affect participation in medical decisions, taking care of relatives, ethical dilemmas and mental health problems. Although most Confucianist influence seems to be positive, some ways of thinking could increase suffering, burnout and a delay in healthcare seeking. Understanding these values could help health professionals to deal with the growing contingent of patients with different cultures and religious beliefs.

'A picture is worth a thousand words'-A photovoice study exploring health professionals' experiences during the COVID-19 pandemic.

AIM: To elicit the experiences and perspectives of health professionals working on the frontline in the COVID-19 pandemic. BACKGROUND: Although some qualitative studies have been carried out in health professionals during COVID-19 pandemic, to our knowledge, no study has used the Photovoice method. DESIGN: A qualitative descriptive study using Photovoice was carried out between March and June 2020. METHODS: A total of 20 health professionals were recruited from public and private healthcare services. The participants were invited to share photographs about their experiences while working during COVID-19 pandemic. Following the Photovoice method, audio-recorded interviews were conducted. The data were analysed using the 'SHOWED' mnemonic, with five questions answered about each photograph. The EQUATOR checklist has been used. RESULTS/FINDINGS: Three themes emerged: (1) Personal attitudes of health professionals; (2) Support from the community; and (3) Management of institutional resources. Despite the fact that health professionals in this study were exposed to major risks while caring for patients with COVID-19' they felt a strong sense of responsibility towards the community. In order to handle these stressful situations, they used coping mechanisms, good humour and leisure, but also received support from the population, who saw them as highly skilled health professionals. CONCLUSION: These findings highlight the essential role of health professionals in the COVID-19 pandemic and the tireless work they are carrying out to provided highly skilled care. RELEVANCE TO CLINICAL PRACTICE: These findings could contribute to raise awareness on the needs of health professionals during the pandemic, allowing managers to plan strategies to ensure the safety, and well-being of these professionals, as well as adopting similar strategies in their practice to create a space for critical reflection through participatory approaches.

Prevalence and factors associated with substance use among Chinese immigrants in Spain: A mixed-design study.

OBJECTIVE: To explore the use of tobacco, alcohol, and illicit drugs and its associated factors among Chinese immigrants living in Spain. DESIGN AND MEASURES: A mixed-method design, using surveys and semi-structured interviews. SAMPLE: A total of 133 Chinese immigrants and stakeholders were assessed in the quantitative study and 7 stakeholders were interviewed in the qualitative study. RESULTS: The use of tobacco and alcohol was higher than the use of illicit drugs in Chinese immigrants. The prevalence of daily smokers was greater in men than in women (37.3% vs. 2.5%, p < .001). Men consumed more alcohol (76% vs. 50.6%, p = .004) and more frequently (21.6% daily vs. 2.4%, p = .024) than women. The use of illicit drugs was low and Cannabis was the most illicit drug consumed (4%). Qualitative data revealed that due to a great workload, the workers tended to avoid behaviors of illicit drug consumption, but not of alcohol and tobacco, in which the consumption is associated with business meetings and leisure. CONCLUSION: This study found that Chinese immigrants in Spain consume more alcohol and tobacco than illicit drugs and that men have a high consumption compared to women. These findings reveal important cultural differences that should be addressed by public health managers in order to develop strategies that consider the characteristics of this population.

"A Temple of God": A Qualitative Analysis of the connection Between Spiritual/Religious Beliefs and Health Among Mormons.

In the last decades, studies have increasingly shown an association between religious/spiritual beliefs (R/S) and several health outcomes. In this context, Mormons provide an intriguing case for such investigation because Mormonism stands out for its commitment to the "Word of Wisdom" with several restrictions and recommendations. Despite the consolidated wide array of evidence, showing that the relationship between "Word of Wisdom" and health may usually have a protective effect in North-American studies, little is know about this community in other countries and, to our knowledge, no health studies have ever been carried out in European and Spanish Mormons. The present qualitative study aims to fill this gap, exploring the discourses, opinions, and attitudes of the members of the Church of Jesus Christ of Latter-day Saints about the recommendations of the Health Law and the "Word of Wisdom" on their health. In the analysis, six themes appeared during the coding process and were converted in the following categories: Theme 1 Body as a Temple, Theme 2 Promises of blessing, Theme 3 Healthy lifestyle, Theme 4 Stigma, Theme 5 Damage to the family, and Theme 6 Spiritual Performance. We found that fulfilling the "Law of Wisdom" may lead Mormons to take care of their health, and to have a network of support from church leaders, who may act as health promoters. Religiosity tends to insert values and behaviours that seem to benefit individual's health and protect their families, such as the non-use of substances and the preservation of a "healthy body" (i.e. "body as a temple"). However, some stigma and isolation may appear in contact with other groups due to these restrictions and limitations.

Correction to: "A Temple of God": A Qualitative Analysis of the connection Between Spiritual/Religious Beliefs and Health Among Mormons.

The original version of the article was inadvertently published with textual error.

Complementary and Alternative Medicine to Treat Fibromyalgia Symptoms. A Systematic Review.

This study aims to investigate the current evidence for the use of complementary and alternative medicine (CAM) in fibromyalgia (FM). A systematic review was conducted searching for PubMed, Scopus, CINAHL, PsycInfo, and Web of Science databases. Randomized controlled trials published up to December 2023 in peer-reviewed journals were included. Methodological quality was assessed by the Quality Assessment of Controlled Intervention Studies tool. A total of 216 articles were identified and 15 constituted the final sample. The type of CAM most used was traditional Chinese medicine (60%), and the most common instrument used was the Fibromyalgia Impact Questionnaire (60%). Our review was grouped into four themes based on the origin of the therapies: 1) Traditional Chinese Medicine; 2) Japanese natural harmonization (eg, Reiki); 3) Ayurvedic Medicine; and 4) Other non-drug therapies. Our systematic review showed that there is a wide range of CAMs used to treat FM. Most of the clinical trials have shown significant results for the effectiveness of these interventions in both physical and mental health outcomes of FM as compared to control groups. However, the heterogeneity of the interventions and outcomes warrants further studies on this topic.

Spiritual needs during COVID 19 pandemic in the perceptions of Spanish emergency critical care health professionals.

OBJECTIVES: To investigate the perceptions and attitudes of health professionals working in emergency services and critical care units in Spain about spiritual care provided during the COVID-19 pandemic. METHODS: A qualitative investigation was carried out using in-depth interviews. SETTING: Emergency and emergency and ICU health professionals from different regions of Spain. FINDINGS: The sample consisted of 47 nursing and one nursing assistant. The qualitative analysis yielded four main themes that reflect the following categories: "the experience with spirituality in clinical practice"; "resources and barriers to provide spiritual care"; "the COVID pandemic and spiritual care" and "training in spiritual care". In addition, two subdeliveries were also obtained: "ethical dilemma" and "rituals of death". CONCLUSIONS: The majority of emergency and critical care nurses believe spiritual care is important to their clinical practice, but there are still several barriers to address patients' spiritual needs. During the COVID-19 pandemic in Spain, professionals felt that spiritual beliefs have emerged as important needs of patients and the restrictions imposed by the pandemic made health professionals more exposed to ethical dilemmas and end-of-life religious issues. The general impression of health professionals is that more training and resources are needed on this topic. IMPLICATIONS FOR CLINICAL PRACTICE: Health professionals in emergency intensive care must provide nursing care that meets the spiritual needs of their patients to improve care in crisis situations such as the one suffered by the COVID-19 pandemic. For this, emergency services professionals must work and participate in the development of measures to overcome certain barriers present in emergency services, such as lack of time, lack of training and misconceptions that make it difficult to approach emergency services these needs.

The use of complementary and traditional medicine for the treatment of patients with COVID-19: A systematic review.

OBJECTIVE: The aim of this study was to evaluate the use and effectiveness of non-pharmacological therapies as part of the treatment of COVID-19 and its complications, either combined or not with the usual treatment. METHODS: A systematic review was conducted between August and October 2021 using PubMed, Scopus, CINAHL and Web of Science databases. From a total of 204 articles identified, 33 were included in the final sample (15 clinical trials and 18 quasi-experimental studies). The methodological evaluation was carried out using STROBE and CONSORT guidelines. RESULTS: There is a growing literature on the use of CAM for COVID-19. Most studies have shown positive findings, particularly for the use of TCM, other herbal therapies and acupuncture. Nevertheless, most studies were carried out in Asia and relied on quasi-experimental designs. The current evidence is available for physical outcomes (mortality rate, pneumonia resolution and other symptoms, negative PCR test, and hospitalization and ICU admissions) and for mental health outcomes. CONCLUSION: Despite a positive role of CAM on COVID-19 outcomes, the evidence is still mostly based on quasi-experimental studies. More robust clinical trials are needed in order to generate better evidence in this area.

Diffusion of person-centred care within 27 European countries - interviews with managers, officials, and researchers at the micro, meso, and macro levels.

PURPOSE: This study aimed to describe facilitators and barriers in terms of regulation and financing of healthcare due to the implementation and use of person-centred care (PCC). DESIGN/METHODOLOGY/APPROACH: A qualitative design was adopted, using interviews at three different levels: micro = hospital ward, meso = hospital management, and macro = national board/research. Inclusion criteria were staff working in healthcare as first line managers, hospital managers, and officials/researchers on national healthcare systems, such as Bismarck, Beveridge, and mixed/out-of-pocket models, to obtain a European perspective. FINDINGS: Countries, such as Great Britain and Scandinavia (Beveridge tax-based health systems), were inclined to implement and use person-centred care. The relative freedom of a market (Bismarck/mixed models) did not seem to nurture demand for PCC. In countries with an autocratic culture, that is, a high-power distance, such as Mediterranean countries, PCC was regarded as foreign and not applicable. Another reason for difficulties with PCC was the tendency for corruption to hinder equity and promote inertia in the healthcare system. RESEARCH LIMITATIONS/IMPLICATIONS: The sample of two to three participants divided into the micro, meso, and macro level for each included country was problematic to find due to contacts at national level, a bureaucratic way of working. Some information got caught in the system, and why data collection was inefficient and ran out of time. Therefore, a variation in participants at different levels (micro, meso, and macro) in different countries occurred. In addition, only 27 out of the 49 European countries were included, therefore, conclusions regarding healthcare system are limited. PRACTICAL IMPLICATIONS: Support at the managerial level, together with patient rights supported by European countries' laws, facilitated the diffusion of PCC. ORIGINALITY/VALUE: Fragmented health systems divided by separate policy documents or managerial roadmaps hindered local or regional policies and made it difficult to implement innovation as PCC. Therefore, support at the managerial level, together with patient rights supported by European countries' laws, facilitated the diffusion of PCC.

Burnout and spirituality among nurses: A scoping review.

OBJECTIVE: To investigate the relationship between spirituality / religiousness and Burnout Syndrome in nurses, as well as to examine the current evidence for spiritual/religious interventions to alleviate their symptoms. DATA SOURCES: A scoping review was conducted using CINAHL, SCOPUS, Web of Science, Pubmed databases, and grey literature, between January and July 2020. STUDY SELECTION: Two researchers performed the searches with a 95% agreement rate for the inclusion and exclusion of the studies. Both quantitative and qualitative studies published in peer-reviewed journals, using Spanish, Portuguese or English language were included. Restriction on publication date was not applied. DATA EXTRACTION: A total of 1143 articles were identified and 18 were included in the final analysis. Quality assessment was performed, following CONSORT, STROBE, PRISMA and COREQ guidelines. Finally, the following data were extracted: authors, year, country, study design and sample characteristics, purpose of the study, and major findings. DATA SYNTHESIS: The results of the present review show that spirituality / religiousness is a common strategy used by nurses when coping with stress and burnout. Most studies reveal that spiritual and religious beliefs are correlated with lower levels of burnout, exhaustion and depersonalization in different settings. Nevertheless, two studies have not found any relationship and one study has found worse outcomes. CONCLUSIONS: There is a lack of experimental studies trying to examine if spiritual interventions could modify burnout levels in clinical practice. Health managers should be aware of the spirituality / religiousness of their nurses and provide the appropriate spiritual support.

[Elderly people, dependency and vulnerability in the coronavirus pandemic: an emergency for a social and health integration]. / Personas mayores, dependencia y vulnerabilidad en la pandemia por coronavirus: emergencia de una integración social y sanitaria.

The current SARS-CoV-2 pandemic (COVID-19) is affecting elderly people worldwide with greater incidence and severity. In Spain, 68% of all coronavirus hospitalizations correspond to those over 60 years of age. This work aims to highlight the evidence about the measures to be implemented through current and future guidelines. The need to prepare for action by implementing international protocols stand out. There is a trend towards biopsychosocial care of elderly people in all settings where they are, adapting care and personalizing decisions on hospital admissions, palliative care, among other criteria, to years adjusted to quality of life, as well as alternatives for monitoring and treatment of COVID-19 pathology and others existing in this population group. Measures to reduce the transmission of the virus through hygiene and social distancing are necessary, attending to biopsychosocial health of the elderly isolated. Intersectoral communication is proposed as innovative alternatives, and the use of technological tools, accompanied by adequate digital health literacy. Future lines focus on guaranteeing social and health rights, equating the social and health system at the same level, and achieving real coordination. A new framework of person-centered care could be a great ally to achieve integrated care for the elderly, guided by an increase in resources bound to funding longevity research projects.

The role of cultural beliefs on eating patterns and food practices among pregnant women: a systematic review.

CONTEXT: Despite the importance of cultural beliefs in clinical practice, few systematic reviews have investigated how these beliefs influence food practices in pregnant women. OBJECTIVE: To explore the role of cultural beliefs in eating patterns and food practices among pregnant women, highlighting food recommendations, food taboos and restrictions, and their association with health. DATA SOURCES: A systematic review was conducted using the following electronic databases: PubMed, Scopus, CINAHL, PsycINFO, and Web of Science from May 2014 to May 2019. DATA EXTRACTION: Articles were included if the studies included pregnant women, analyzed how cultural beliefs may influence eating patterns, were peer-reviewed articles with original data, published in the last 5 years, and in English or Spanish language. Quality assessment was also performed. DATA ANALYSIS: A total of 544 articles were identified in the search and 24 were included in the final analysis (17 using qualitative design, 6 using quantitative design, and 1 with a mixed-design). These studies were predominantly from the African continent (n = 15). Our findings showed that culture is a key factor related to "taboos" and food restrictions, which are transmitted by the family or members of community, having a strong religious or spiritual influence. All these restrictions are related to the fear of unfavorable pregnancy outcomes such as the risk of abortion, dystocia, and congenital macrosomia, or are used to avoid child problems such as cutaneous and respiratory disorders. CONCLUSIONS: Findings from this study indicate cultural beliefs are strongly associated with food patterns and eating habits in pregnant women. Administrators and health professionals should be aware of these beliefs to minimize problems in the perinatal period.

Health Problems and the Use of Medications and Traditional Therapies among Chinese Immigrants Living in Spain.

In this study, we investigate the health problems and the use of medications and traditional therapies among Chinese immigrants in the Southern region of Spain. A qualitative study using semi-structured interviews and including 133 immigrants and 7 stakeholders was conducted in 2017. Transcription, literal reading, and theoretical categorization were performed, and a narrative content analysis was carried out. The most common health problems were musculoskeletal (28.6%) and allergies (25.6%) related to work activity and unhealthy lifestyles. Key informants also reported gastric problems, stress, and changes in eating habits, mostly related to their work activity. For these problems, a large number of traditional remedies (herbs, diet therapy, acupuncture, vitamins, etc.) were used, usually combined with pharmaceutical drugs used for colds, flu, general malaise (29%), pain and fever (23%), and allergy drugs (9.2%). Chinese immigrants reported health conditions associated with their working conditions and life habits in Spain, using Traditional Chinese Medicine instead of pharmacological drugs. Understanding these health problems and promoting awareness towards traditional therapies in the healthcare system may help to design public policies and Health Promotion strategies targeting this group.